The present invention is directed to systems and methods for comprehensively assessing and optimizing the administration of healthcare as rendered by a group of physicians to a specific patient population. More particularly, the present invention comprises systems and methods that conserve medical resources utilized to care for the patient population, ensure uniformity in the procedures/tests utilized to render such care, identify and assess those patients afflicted with a chronic condition requiring high-cost healthcare, and provide means to continuously monitor and evaluate the quality of healthcare delivered.
Essential to high quality and cost-effective health care is the proper diagnosis of a patient's condition. From a proper diagnosis, the appropriate medical attention utilized to treat the underlying condition, whether it be the performance of a medical procedure, laboratory tests and/or prescription of medication, can be determined. To that end, and as is well-known in the art, standard diagnoses codes are extensively utilized pursuant to conventional disease classification techniques that provide a quick, well-understood method to document medical care administered to a patient. Exemplarily of and perhaps most widely utilized of such formats is the International Classification of Diseases 9th Edition (ICD number 9) three digit codes. Likewise, with respect to the medical treatment that has been rendered, such procedures are typically referenced according to Current Procedural Terminology (CPT). Also frequently referenced in connection with the delivery of health care are drug codes (e.g., NDC), other service codes (e.g., HCPCS), among others.
Notwithstanding such basic principles of medicine, as well as an infrastructure of coding practices to help facilitate the delivery of health care and documentation of patient treatment, the current administration of healthcare in the United States is subject to tremendous abuse and is grossly inefficient. In this regard, patients, healthcare providers and healthcare providing institutions often encourage wasteful practices that result in needless procedures and tests being performed. Moreover, healthcare providers and healthcare providing institutions, such as hospitals, clinical laboratories, outpatient and rehabilitation facilities, engage in capricious billing practices that enable such providers and institutions to charge for a multiplicity of services that may be available under a single clinical event that is typically identified by a single CPT code.
Further problematic with such practice is that healthcare providers and healthcare providing institutions frequently utilize the wrong codes for diagnosis or otherwise use incorrect or multiple CPT codes to seek reimbursement, whether it be from an insurance company, health maintenance organization or government sponsored healthcare program, such as Medicare. In this regard, by failing to follow any type of uniform healthcare delivery system, and hence uniform coding practice commensurate therewith, results in overcharges for procedures that have been unnecessarily performed, improper diagnosis and duplicative and unnecessary tests and procedures.
In addition to health care providers and institutions, patients themselves contribute substantially to the cost and ineffective utilization of health care resources. As is well-known, patients can and frequently do seek unnecessary medical treatment or otherwise attempt to influence the judgment of the health care provider by demanding that unnecessary tests or procedures be performed, that the patients have access to specialists or particular medications, and/or seek in-patient services in situations where the patient's clinical condition clearly does not justify such level of care. Such potential abuses are particularly likely where patients are allowed the discretion to directly access specialists, as is typical in several well-known health care insurance plans, such as Blue Cross and Blue Shield, which thus bypasses the critical role played by the primary care physician in making an initial assessment of a patient's condition and whether the same truly warrants the attention of a particular specialist, and not to mention the specialist best suited to handle a particular condition.
Such conventional health care practices are particularly wasteful in the context of providing healthcare to patients afflicted with a chronic condition requiring aggressive medical management. Such conditions, known as high-cost chronic conditions, include cancer, cardiovascular disease, diabetes, HIV, liver disease and pulmonary disease, among several others. To treat such high-cost chronic conditions typically involves continuous patient treatment, which may take the form of a variety of medical procedures, tests, prescription medicines, and the like, as well as continuously monitoring the patient's condition to make sure that the underlying chronic condition does not develop to a more advance state, develop complications, and/or give rise to further related medical condition. Current practices, however, are ill suited to dynamically treat the progression of disease, and most physicians and healthcare institutions merely react to the patient's condition as opposed to be proactively involved in and anticipate the potential future needs of the patient. Such lack of responsiveness is typically reflected in the coding practices associated with the care delivered to the patient, which often times can be inaccurate and inappropriate based upon a general lack of patient history documentation and anticipated need to follow up with the patient. As a result of such poor practices, medical costs associated with the treatment of chronic conditions become astronomical and almost always beyond the capability of most individuals to pay.
In order to counter such wasteful and abusive practices, attempts have been made to implement certain procedures to contain health care costs and conserve the utilization of health care resources. Exemplary of such attempts include requiring prior authorization and approval by an intermediate entity, such as a health maintenance organization or health insurance plan, to the extent a physician seeks to take a specified action, such as perform surgery, order a medical supply or refer the patient to a specialist. Also utilized are the practices of bundling, whereby a physician is paid a single payment for two or more medical services, and capitation whereby a health care provider is paid a set dollar amount as determined by a per member, per month calculation to deliver medical services to a specific patient population (i.e., members of a health maintenance organization). Still further examples include the use of preferred provider discounts, which encourage the use by patients of specific health care providers, and usual and customary reductions, which impose a reduction in the payment of medical services rendered as deemed justified by a health plan or insurance company based upon what is considered to be the justified value of such services as rendered in a particular geographical area.
Despite such attempts, however, there has yet to be devised any type of health care administration system or method that substantially conserves utilization of health care resources that, as a consequence, can dramatically lower the costs associated with providing care to a specific patient population, especially in connection with the treatment of patients with high cost chronic conditions. Such attempts have likewise failed to maintain any degree of consistent quality of health care insofar as prior art cost containment practices have been and continue to be riddled with “loopholes” with insufficient cost-deterrent mechanisms necessary to conserve and optimally utilize a finite amount of health care resources to treat accurately diagnosed patients.
As a result of the aforementioned abuses and inefficiencies associated with the utilization of health care resources, the cost of health care has and continues to increase substantially while the quality of the health care provided has not necessarily improved. As such, there is a substantial need in the art for a health care administration system and method that are operative to effectively and efficiently utilize health care resources to administer care to a patient population as compared to conventional practices. There is additionally a need for a healthcare administration system and method that utilizes a standardized coding practice that adheres to a standardized diagnosis treatment scheme that can be reviewed for accuracy and physician competency. There is still further a need in the art for such a system and method that is generally effective in eliminating the wasteful practices associated with the allocation and utilization of health care resources, especially in connection with the treatment of patients affected with chronic ailments, without adversely compromising clinical outcomes or quality of care.